건강보험 진료비 보상방식과 일차진료의사 서비스
Payment systems and the performance of primary care physicians
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한정된 보건의료자원하에서 건강보험재정 절감 및 환자 진료의 적절성 확보는 수가정책의 중요한 목표일 것이다. 그런데 우리나라의 건강보험 하에서 의료공급자에 대한 진료비 보상방식, 즉 행위당수가제와 수가 통제는 과잉진료 및 건강보험진료비 증가라는 문제를 극복하는 데 성공적이지 못하였다. 비대칭적 정보로 초래되는 불완전한 대리인 문제를 해결하기 위해서는 적절한 유인 설계가 필수적인데, 본 연구에서는 본인-대리인 모형을 이용하여 바람직한 진료비 보상방식이 지녀야할 유인 체계에 대해서 살펴보았다. 보다 나은 일차진료의사 서비스를 유도하기 위한 유인 체계는 수가 수준 조절뿐만 아니라 적절한 위험 분담을 포함하는 것이 바람직한데, 그 동안 우리나라 건강보험 하의 진료비 보상방식은 수가 수준을 통제하는 데만 집중하였다는 문제점이 있다. 향후 새로운 수가정책의 대안으로서 일차진료의사에게 재정적 위험을 적절히 분담시키는 방안이 필요하다. 단기적으로 현행 행위당수가제를 유지하면서 일차진료의사가 제공하는 서비스의 양이나 질에 따라서 재정적 위험을 분담하는 방안과, 중장기적으로 행위당수가제 이외의 다른 진료비 보상방식, 예컨대 총액계약제 혹은 혼합 진료비 보상방식을 도입하는 방안에 대해 면밀한 검토가 요구된다.
Abstract
Given limited health resources, a payment system aims to achieve both appropriateness of services and cost containment. Fee-for-service payment with fee control, implemented since the inception of health insurance in Korea, has not been successful in achieving those aims The principal-agent model tells that only incentive-compatible payment can make primary care physicians provide services in the interest of patients. To satisfy incentive compatibility, it is necessary to design a payment system whereby primary care physicians bear some financial risk resulting from service provision. One option for financial risk sharing is to adjust reimbursement level for primary care physicians ex post depending the volume or quality of services they provide under the fee-for-service system. To change FFS into a different payment like global contract or a mixed payment can be another option.
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